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r 7 <br /> RECEEIVED <br /> Secondary Containment Testing Report Form DEC 01 2014 <br /> This form is•intended for use by contractors perform in <br /> appropriate Pages uf'thrsriadic testing of UST sccona+ur} contar <br /> Jornr to report results for all components tested The completedform, WWAL e HEALTH <br /> prrnror,ts from tests(�`ppplicableJ,should be provided to the facility owner/o erutor or submittal to the IU T <br /> p f <br /> 1. FACMITY INFORMATION <br /> Facility Marne: ,p �, <br /> Facility Address . Date of Testing: f l <br /> Facility Contact- <br /> Date Local Agency Was Notified of Testing: ll Phone: <br /> Name of Local Agency Inspector ffprosenl Burin testing) �o[T f t' ..•.. <br /> 2. <br /> Company NameTESTING CONTRAC OR INFORMATION <br /> : AB1.,E Maintenance, Jnc, <br /> Crede <br /> Technician Conducting'1'est:( n00�Q <br /> Credentials— _�— ' l GlT <br /> ® CSLB Licensed Contractor i ---_-, <br /> I SWRCB Licensed Tank Tester <br /> License Type:A, 13,Haz.,C 1 : <br /> ___ License Number: 312844 �m— <br /> MRnufacturerTrainin <br /> IVlanufacturer <br /> Available 11 re hest Com onent s) - <br /> ----_----13ate_7'rainin Ex ices <br /> 3` SUMMARY OF TEST RESULTS <br /> Component. Pass Fail Not I Repairs <br /> Tank Annular - Vested I Made Dotes: <br /> Secondary Pie - ❑ ❑ ❑ ❑ - —�--_ _. _ <br /> Turbine Sump - ❑ 0 <br /> Q t F S4- <br /> I t TJl <br /> Fill sum ❑ <br /> e ❑ �, c� ❑ <br /> TLM sump <br /> ❑ o ❑ <br /> Spill Bucket - ❑ ❑ ❑ <br /> If hydrostatic testingwas , <br /> performed,describe what was done with the water after com,plcrion of tests: <br /> --* — <br /> ------------ <br /> CERTIFICATION OF TEC)INIC1AN RESPONSISLE FOR CONDUCTING THIS TEST)NYC _ <br /> 1'a the best Of my knowledge,the facts sla ed in this document are accurate and In full con:pliance with legal requirements <br /> Technician's Signatur <br /> �....�._-- <br />